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Send Orders for Reprints to email@example.com Clinical Practice & Epidemiology in Mental Health, 2018, 14, 109-119 109 Clinical Practice & Epidemiology in Mental Health Content list available at: www.benthamopen.com/CPEMH/ DOI: 10.2174/1745017901814010109 RESEARCH ARTICLE Domestic Violence as a Risk Factor for Postpartum Depression Among Ethiopian Women: Facility Based Study Addishiwet Fantahun Adamu1 and Yohannes Mehretie Adinew2,* 1 College of Health sciences, Addis Ababa University, Addis Ababa, Ethiopia 2 College of Health sciences and Medicine, Wolaita Sodo University, Sodo, Ethiopia Received: March 12, 2018 Revised: April 20, 2018 Accepted: April 25, 2018 Abstract: Background: Mental illness in women leads to an increased maternal morbidity and mortality. Postpartum depression accommodates various groups of depressive disorders and syndromes that occur within the first immediate year after delivery. Thus, this study aimed to assess the prevalence of postpartum depression symptoms and correlates among mothers attending public health centers of Addis Ababa, Ethiopia. Methods: Facility-based cross-sectional study was conducted on 618 women in their postpartum period. Simple random sampling technique was used to select three out of ten sub cities in Addis Ababa. Then, nine health centers were selected by lottery method from the three sub-cities. The number of women included from each health center was determined by proportional allocation. Study participants were enrolled by systematic random sampling. The Edinburgh Postnatal Depression Scale was used at a cutoff point >13 to detect depression. Descriptive statistics were done. The bivariate and multivariate analysis was also carried out to identify predictors of postpartum depression. Results: Significant proportion 144 (23.3%) of the women had the symptom of postpartum depression. Respondents who were the victims of domestic violence [AOR 3.1; 95% CI: 1.6-5.9], reported to have diagnosed with postpartum depression [AOR 4.41; 95% CI: 2.4-8.3], and dissatisfied with their marriage [AOR 2.9; 95% CI: 1.5-5.6] had higher odds of reporting postpartum depression symptoms. Conclusion: Postpartum depression is a common mental health problem during the postnatal period. Domestic violence was positively and significantly associated with the symptom of postpartum depression. Maternity services shall consider a sector that provides health care for women who encounter violence and develop symptoms of postpartum depression. Keywords: Depression, Postpartum depression, Maternal mental health and Ethiopia, 'omestic, Domestic violence, Victims. 1. BACKGROUND Postpartum Depression (PPD) explains various groups of depressive symptoms and syndromes that occur during the first immediate year after delivery . It can be described by symptoms like lack of interest, low self-esteem, easily fatigability, sadness, sleep disturbance, loss of appetite , low concentration and inability to make decision, meaningless of life, negative attitude toward the baby and feeling of guilt and shame . * Address correspondence to this author at the College of Health sciences and Medicine, Wolaita Sodo University, Sodo, Ethiopia; Tel: +251 91-202-1605; E-mail: firstname.lastname@example.org 1745-0179/18 2018 Bentham Open
110 Clinical Practice & Epidemiology in Mental Health, 2018, Volume 14 Adamu and Adinew Globally, 8-19% of women have frequent symptoms of PPD ; this figure is higher in developing countries- 19.8% . PPD is a major worldwide maternal mental health problem which leads to an increased maternal mortality, through adversely affecting physical health needs and more directly through suicide . As a result, children’s growth and future life are tremendously affected by lack of mother-child bonding, lack of breastfeeding, and poorer care . Basically, almost all women are at risk of mental health problems during pregnancy and postnatal period in the immediate first year after delivery. Among the factors that lead women to develop postpartum depression, domestic violence is the major . Violence has devastating consequences on women's physical, psychological, mental and reproductive health: disability (up to loss of life), unwanted pregnancy, depression, loss of confidence and sexually transmitted diseases to mention few [6, 7]. These consequences of violence further have an emotional impact and are also linked to negative health behaviors, such as substance abuse and mood disorders like mania and depression [8, 9]. Despite its disastrous effects especially in low income countries, PPD is not understood well . Therefore, it is mandatory to have an insight into and a plan for the implementation of strategies on prevention and early identification of the problem. Thus, the study was aimed to assess the prevalence and factors associated with the symptom of postpartum depression among mothers attending public health centers in Addis Ababa, Ethiopia. 2. METHODS 2.1. Study Design and Area Facility-based cross-sectional study was employed in selected health centers of Addis Ababa city, the capital of Ethiopia, from Jan to Feb 2017. Addis Ababa has a total population of 3,048,631; of which 52.3% are females . The city has a total of 11 public hospitals, 90 health centers, 31 private hospitals and 700 different level private clinics . The study populations were women who came to sampled health centers for postnatal care and vaccination services within the first six weeks after delivery. 2.2. Sample Size Determination and Sampling Procedure The sample size was determined using single population proportion formula. Based on a significance level of 95%, 4% margin of error, 19.8% prevalence of PPD among study subjects , 10% for possible nonresponse and 1.5 design effect, making the total sample size 629. Multistage sampling technique was employed to select the respondents. Three sub cities namely Bole, Kolfe keranio and Yeka were randomly selected by names from hat method out of the ten sub-cities of Addis Ababa city administration. Then, nine health centers, three from each of the sampled three sub-cities, were selected by lottery, names from hat method. The number of women included in the study from the selected health centers was determined using the proportion to size allocation technique on the basis of previous three-month data from the respective health centers. Participants were enrolled to the study by systematic random sampling technique. To identify the interval, the average number of women expected per day in each health center was divided by the number of women to be interviewed per day from respective health centers. The first woman was selected by lottery method and then every other (second) woman (calculated for each health center) visiting the health centers was enrolled to the study. In case a woman we approached refused, we enrolled the next immediate woman. 2.3. Variables of the Study 2.3.1. Dependent Variable Postpartum depression 2.3.2. Independent Variable Socio-demographic characteristics, social support, obstetric factors and psychiatric history 2.4. Operational Definitions 2.4.1. Postpartum Depression Symptoms According to Edinburgh Postnatal Depression Scale (EPDS) questions 1, 2, & 4 were scored 0, 1, 2 and 3 with the first choice scored as 0 and the last choice scored as 3. Questions 3, 5-10 are reversely scored, with the first choice
Violence Postpartum Depression Based Study Clinical Practice & Epidemiology in Mental Health, 2018, Volume 14 111 scored as 3 and the last choice scored as 0. After adding up all the scores, those women who scored >13 were defined to have symptoms of postpartum depression [13, 14]. 2.4.2. Postpartum Period A period beginning immediately after the birth of a child and extending to the sixth week. 2.4.3. Social Support Social support was measured using the Maternity Social Support Scale (MSSS) developed by Webster and colleagues . The scale contains six items and includes questions on family support, friendship network, help from spouse, conflict with spouse, feeling controlled by spouse, and feeling unloved by spouse. Each item was measured on a five-point Likert scale and a total score of 30 was possible. We classified social support into two categories; high social support (for scores 18–30) and low social support (below 18) categories. The internal consistency of the scale was tested using Cronbach’s alpha and was found to be 0.74. 2.4.4. Domestic Violence It is defined as being the victim of domestic violence during perinatal period if she reported any of the following experiences with a husband or a partner: having something thrown at her; being pushed, or slapped, or kicked, or beaten up; being threatened or attacked with any weapon; being physically forced to have sex and/or perform any sexual act when not have the desire. 2.4.5. Data Collection Tool and Procedures A structured interviewer-administered questioner was used to collect data. The instrument was adopted from previous researches [10, 16 - 22]. The questioner was designed in English and translated to local language, Amharic and then back to English by a third person to cheek for internal consistency. The tool composed of two sections; the first section involved four parts. Part one had 15 questions about socio-demographic characteristics, part two had 11 questions concerning obstetric factors, part three had 2 questions related to past psychiatric history and part four involved 6 items on social support. Section two had 10 questions on EPDS that indicates how the mother has felt during the previous 7 days. The EPDS is widely used and has been validated for use in different countries and settings [23 - 27], including urban and rural part of Ethiopia [25, 28] to identify postnatal depression symptoms and has generated sensitivity and specificity of 78.9% and 75.3% respectively . Thus, it is recommended that the EPDS be used in routine postnatal screening . Five diploma nurses, who were not the employees of the selected health centers, collected the data. 2.4.6. Data Quality Control Management Appropriate training and supervision was given to data collectors. The instrument was pretested in Arada health center on 32 postnatal women and necessary revisions, and sequence rearrangement of questions to remove the redundant ones, were made prior to the actual data collection. 2.4.7. Data Analysis Procedure Filled data were checked for completeness and entered to Epi data and then exported to SPSS version 21 for further analysis. Descriptive statistical analysis was carried out. Both bivariate and multivariate logistic regression models were also carried out to identify associated factors. Odds ratios and their 95% confidence intervals were computed and variables with p value < 0.05 were considered significant. 3. RESULTS 3.1. Socio-Demographic Characteristics A total of 618 post-partum women responded fully to all the questions out of 629 requested to participate, yielding a response rate of 98.2%. The number of participants included in the study was 197(32%) form Bole, 229(37%) from Kolfe keranio and 192(31%) from Yeka sub-cities. The median age of the respondents was 28 years (range; 16-46 years). Majority (526, 85.1%) were married, while 502(81.2%) of the participants had attended formal education. Two hundred eighty-one (45.5%) of the respondents were housewives (Table 1).
112 Clinical Practice & Epidemiology in Mental Health, 2018, Volume 14 Adamu and Adinew Table 1. Socio-Demographic characteristics among women in postpartum period, in health centers of three sub-cities of Addis Ababa, Ethiopia (N=618). Characteristics - Depression - - Yes No Age in years 15-24 32 (23.1) 106 (76.9) - 25-34 95 (15.2) 315 (32.1) - >35 17 (2.9) 53 (5.9) Marital status Married 122 (19.8) 404 (65.3) - Unmarried 22 (3.5) 70 (11.4) Attended school Yes 100(19.9) 402(80.1) - No 44(37.9) 72(62.1) Level of education (502) Primary school 39 (23.9) 82 (76.1) - Secondary school 23 (21.4) 84(78.6) - Technical or vocational 6 (10.5) 51(89.5) - Diploma 25 (22.4) 87(77.6) - Degree and above 22 (20.9) 83(79.1) Occupational status Employed 67(19.9) 270(80.1) - Housewife 77(27.4) 204(72.6) Difficult with income Yes 71 (33.8) 139(66.2) - No 73 (17.8) 335(82.1) Monthly average income 3501 59 (30.8) 132(69.1) 3.2. Obstetric and Clinical Characteristics More than a third (228, 36.9%) of the participants reported that it was their first pregnancy; and for 179 (29%) women, the pregnancy was unplanned. About one-fifth (136, 22.0%) of the respondents were not happy with the sex of their last baby. The prevalence of caesarian delivery was 131 (21.2%). Furthermore, one-fourth of the participants 164(26.5%) had suffered from illnesses (obstetric and non-obstetric) for which they had sought treatment, during their pregnancy. It was also reported that 21(3.4%) of the respondents’ recent pregnancy was eventfull (Table 2). Table 2. Participants Obstetrics and clinical characteristics in postpartum period, from health centers of three sub-cities of Addis Ababa, Ethiopia (N= 618). Depression Characteristics Yes No 1 33(14.4) 195(85.6) Number of pregnancy 2-3 82(26.3) 229(73.7) ≥4 29(39) 50(63.2) Yes 87(19.8) 352(80.2) Planed pregnancy No 57(31.8) 122(68.2) Male 80(26) 227(74) Sex of last baby Female 64(20.5) 247(79.5) Undesired 30(22.1) 106(77.9) Desired sex of the baby Desired 36(17.4) 171(82.6) I don’t mind 78(28.4) 197(71.6) Vaginal 99(23.8) 317(76.2) Mode of delivery Instrumental delivery 25(35.2) 46(64.8) Cesarean section 20(15.3) 111(84.7) Yes 43(26.2) 121(73.8) Illness during pregnancy No 101(22.2) 353(77.8) Yes 19(47.5) 21(52.5) Experience death of a baby No 125(21.5) 453(78.5)
Violence Postpartum Depression Based Study Clinical Practice & Epidemiology in Mental Health, 2018, Volume 14 113 (Table 2) contd..... Depression Characteristics Yes No Yes 32(30.7) 72(69.3) Hospitalized child No 112(21.7) 402(78.3) Yes 6(28.5) 15(71.5) Stressful life event during pregnancy No 138(23.1) 459(76.9) 3.3. Personal and Family history of Depression and Social Support Among the Women Among women who had previously given birth, 93 (23.8%) of them reported that they had been diagnosed with PPD. In addition, 90 (14.6%) of the respondents had a family history of depression. Eighty-seven (14.1%) of the study participants reported they had experienced domestic violence. Nearly one-fifth (113,18.8%) of the women described their relationship with their husband as unsatisfactory and 104 (16.8%) of the respondents reported not being enough social. Regarding the relationship they had with their mother in law, 178 (28.8%) stated that they were unhappy (Table 3). Table 3. Personal and family history of depression and social support among postpartum women’s, from health centers of three sub-cities of Addis Ababa, Ethiopia (N= 618). Depression Characteristics - Yes No Yes 53(57.0) 40(43.0) Previous history of depression No 91(17.3) 434(82.7) Yes 33(36.6) 57(63.4) Relatives suffered from mental illness No 111(21.0) 417(79.0) Yes 52(59.8) 35(40.2) Abuse/domestic violence No 92(17.3) 439(82.7) Yes 77(15.2) 428(84.8) Satisfied with marriage No 67(59.3) 46(40.7) Yes 64(12.4) 450 (87.6) Social support No 80(76.9) 24 (23.1) Yes 123(21.9) 437 (78.1) Relatives present during labor No 21(36.2) 37 (63.8) Yes 88(20.0) 352(80.0) Satisfied in relation with mother-in-law No 56(31.5) 122(68.5) 3.4. Prevalence of Postpartum Depression Symptoms A significant proportion of 144(23.3%) women had symptoms of postnatal depression; the score ranged from 1 to 28 in the overall sample. Fifty-one (8.3%) of the respondents scored 1 while only two (0.3%) scored 28. 3.5. Edinburgh Postnatal Depression Scale (EPDS) Responses Among Participants About one-tenth (69,11.2%) reported that they were not able to laugh and see the funny side of things. For forty- eight (7.8%) of the participants, it was so difficult to look forward with enjoyment to things. Nearly one-tenth (58, 9.4%) of the women were blaming themselves unnecessarily. Nearly one-sixth of the study participants were anxious or worried for no good reason. In addition, 25(4.0%) stated that they couldn’t be able to cope up with things at all. For twenty-six (4.2%) of the study participants, it was difficult to sleep most of the time. In addition, 18(2.9%) were unhappy and have been crying most of the time and only 2 (0.35%) had a thought of harming themselves (Table 4). Table 4. Edinburgh postnatal depression scale responses among postpartum women’s, from health centers of three sub-cities of Addis Ababa, Ethiopia (N= 618). Characteristics Frequency Percentage Experienced laugh and see funny side of things As much as always I could 394 63.8 Not quite so much now 102 16.5 Definitely not so much now 53 8.6 Not at all 69 11.2
114 Clinical Practice & Epidemiology in Mental Health, 2018, Volume 14 Adamu and Adinew (Table 4) contd..... Characteristics Frequency Percentage Look forward with enjoyment to things As much as I ever did 385 62.3 Rather less than I used to 125 20.2 Definitely less than I used to 60 9.7 Hardly at all 48 7.8 Blamed yourself unnecessarily No never 309 50.0 Not very often 119 19.3 Yes some of the time 132 21.4 Yes most of the time 58 9.4 Been anxious or worried for no good reason No not at all 319 51.6 Hardly ever 70 11.2 Yes sometimes 175 28.3 Yes very often 54 8.7 Felt scared or panic for no good reason No not at all 375 60.7 No, not much 102 16.5 Yes, sometimes 111 18.0 Yes, quite a lot 30 4.9 Things have been on top of you No I have been coping 388 62.8 No most of the time 166 18.8 Yes sometimes I haven’t been coping as well as usual 89 14.4 Yes most of the time I haven’t been able to 25 4.0 Difficult to sleep No, not at all 375 60.7 Not, very often 144 23.3 Yes sometimes 73 11.8 Yes most of the time 26 4.2 Felt sad or miserable No, not at all 386 62.5 Not, very often 149 24.1 Yes sometimes 62 10.0 Yes most of the time 21 3.4 So unhappy you have been crying No, never 410 63.3 Only occasionally 149 24.1 Yes quite often 41 6.6 Yes, most of the time 18 2.9 Thought of harming your self Never 544 88.0 Hardly ever 41 6.6 Sometimes 31 5.0 Yes, quite often 2 0.3 3.6. Factors Associated with Symptoms of Postpartum Depression The result of the multivariate analysis showed that domestic violence, previous history of mental health problem and dissatisfaction with the relationship were positively associated with symptoms of postnatal depression. Domestic violence was found to affect postnatal depression. Respondents who experienced domestic violence had three [AOR: 3.1, 95% CI: 1.6, 5.9] times the odds of reporting symptoms of postpartum depression in contrast to those who had no history of domestic violence. Similarly, participants who were unhappy about their relationship had about three [AOR: 2.7, 95% CI: 1.4, 5.2] times the odds of developing symptoms of postpartum depression than their
Violence Postpartum Depression Based Study Clinical Practice & Epidemiology in Mental Health, 2018, Volume 14 115 counterparts. Furthermore, the previous history of postpartum depression was also found to have an association with the re-attack of postpartum depression. Respondents who had been previously diagnosed for depression had four [AOR: 4.2, 95% CI: 2.3, 7.8] times higher odds of reporting symptoms of depression than those who had no previous history (Table 5). Variables such as educational status, occupational status, mode of delivery, relationship with mother-in-law and sex of the newborn didn’t show any association with symptoms of postpartum depression. Table 5. Bivariate and multivariate logistic regression analysis output of factors associated with postpartum depression among postpartum women from health centers of three sub-cities of Addis Ababa, Ethiopia (N=618). Depression Crude OR Adjusted OR Variables Yes No [95% CI] [95% CI] Yes 100(19.9) 402(80.1) 1 1 Attended School No 44(37.9) 72(62.1) 2.5(1.6,3.8) 0.8(0.4,1.5) Employed 67(19.9) 270(80.1) 1 1 Occupation Unemployed 77(27.4) 204(72.6) 1.5(1.0,2.2) 1.0(0.6,1.8) CS 20(15.3) 111(84.7) 0.6(0.3,1.0) 0.5(0.2,1.0) Mood of Delivery Instrumental 25(35.2) 46(64.8) 1.7(1.0,3.0) 0.8(0.4,1.8) Vaginal 99(23.8) 317(76.2) 1 1 Yes 53(57.0) 40(43.0) 6.3(4.0,10.1) 4.2(2.3,7.8)** History of Depression No 91(17.3) 434(82.7) 1 1 Yes 52(59.8) 35(40.2) 7.1(4.4,11.5) 3.1(1.6,5.9)** Domestic Violence No 92(17.3) 439(82.7) 1 1 Yes 77(15.2) 428(84.8) 1 1 Happy in Marriage No 67(59.3) 46(40.7) 8.1(5.2,12.7) 2.7(1.4,5.2)** Happy 88(20.0) 352(80.0) 1 1 Relation With Mother-in-law Not happy 56(31.5) 122(68.5) 1.8(1.2,2.7) 0.8(0.5,1.5) Undesired 30(22.1) 106(77.9) 0.7(0.4,1.2) 1.0(0.5,2.0) Desired Sex of Newborn Desired 36(17.4) 171(82.6) 0.5(0.3-0.8) 1.0(0.6,1.8) I don’t mind 78(28.4) 197(71.6) 1 1 CS: Cesarean section; Instrumental: Instrumental delivery 4. DISCUSSION Reproductive age women are vulnerable to mental health problems especially during pregnancy and postpartum period as a result of domestic violence [30, 31]. This study also certifies the role of intimate partner violence on postpartum depression among postnatal women to be significant along with the previous history of mental health problem and dissatisfaction in marriage. Significant proportion of women i.e 144 (23.3%) women experienced symptoms of postpartum depression implying that the problem is now becoming a substantial concern for which services are urgently needed. This was somewhat comparable with studies from China 27.37% , City of Poland 23.2%  and Lahore 25% . However this figure was higher compared to findings from Japan 7.7% , Canada 8.69% , Qatar 18.6%  Turkey 15.4%  and Sudan 9.2% . This discrepancy might be explained by different tools, assessment period and methods used. For instance, the study in Japan was conducted by using Japanese version of 12 questions which assessed the general health status of participants at fourth month after delivery by taking ≥4 as cut-off score. Whereas in a study from Qatar, depression anxiety stress scale was used for face to face interview. On the other hand, similar studies from Ethiopia found a higher prevalence report than the present study 32.8%  in Amhara region and 31.5%  in Oromia region. Likewise, studies from Iran , South Africa  and Uganda  also reported an elevated prevalence of symptoms of postpartum depression. As observed from this and other studies, it was evident that domestic violence was a major determinant factor of postpartum depression [AOR: 3.1, 95% CI: 1.6, 5.9]. Despite variability in methodology and definitions of abuse, findings from different parts of the world showed a strong relationship between abuse and risk of postnatal depression. In this study violences were typically physical and verbal (insulting) abuses. A systematic review of literature also revealed a significant association between abuse and PPD . In addition, other studies from Canada , China , Chili  and Pakistan  stated that participants with some sort of intimate partner abuse before or during pregnancy presented with the symptom of postpartum mental health problems. In a cohort study from Iran , women who were screened positive for postnatal depression had been abused.
116 Clinical Practice & Epidemiology in Mental Health, 2018, Volume 14 Adamu and Adinew Moreover, participants who had previously diagnosed with PPD were found to have higher odds [AOR: 4.2, 95% CI: 2.3, 7.8] of reporting the symptom of postnatal depression. This substantial higher risk of postpartum depression was concordance with many other findings which reported a magnified likelihood of depression among individuals who had a previous history of mental health problem [33, 34, 48, 49]. Furthermore, a study from Brazil  revealed that postpartum depression was not only related with the personal history of mental health problem but also a family history of depression. This finding was again supported by another study which was conducted on pregnant women in Addis Ababa, Ethiopia . Stressful moment of pregnancy and delivery could be the reason for relapse of depression among women who had previously diagnosed with PPD. Hormonal imbalance during pregnancy could also be another reason. In the present study, 113(18.8%) of participants were unhappy with their marriage and discovered that women who had a deprived relationship with their partners had higher scores of postpartum depression symptoms [AOR: 2.7, (95% CI: 1.4, 5.2]. Likewise, studies carried out on Ugandan  and Iranian  women were also in agreement with this finding; loss of satisfaction in marriage would be a contributing factor to the symptom of postpartum depression. Besides, a literature reviewed from seventeen studies with a total of 19,132 Arab women found unsatisfactory relationship to be a significant risk factor for mental health problem in postpartum period . Constantly this problem was also highlighted by another literature review conducted on similar study subjects . 5. LIMITATIONS OF THE STUDY The study was limited to six weeks postpartum; the persistence of depression symptoms beyond those weeks of postnatal period was not considered, plus since sexual violence and mental illness are sensitive topics, it is very prone to reporting bias, in most cases, women tend to under-report; thus the prevalence might be somehow underestimated. This study has shared the limitations of cross-sectional studies, the difficulty in determining causal relationships between variables. AUTHORS CONTRIBUTIONS AF: Initiation of the study, Design, Implementation, analysis and Write-up; YMA: Design, Analysis and Write-up as well as prepared the manuscript for publication. All authors read and approved the final manuscript. CONCLUSION Domestic violence is positively associated with the symptom of postpartum depression. Thus, counseling in maternity services should consider the mental disorder-related healthcare needs of those who experienced violence. Further large prospective cohort studies are warranted to identify the relationship between violence and depression. LIST OF ABBREVIATIONS EPDS = Edinburgh Postnatal Depression Scale PPD = Postpartum Depression AVAILABILITY OF DATA AND MATERIALS Data supporting this finding are available and can be accessed with reasonable inquiry. ETHICS APPROVAL AND CONSENT TO PARTICIPATE Ethical approval was obtained from research ethical committee of Addis Ababa University. Health centers were communicated by official letter. Participants were interviewed in a separate room to ensure their privacy. Anonymity and confidentiality of the data providers were strictly maintained by avoiding names and other personal identifiers from the questionnaire. Participants identified with depressive symptoms were linked with mental health clinics. HUMAN AND ANIMAL RIGHTS No Animals/Humans were used for studies that are base of this research. CONSENT FOR PUBLICATION Data were collected only after written informed consent was obtained from each participant.
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